Allied Physicians & Rehab of Southern Illinois, S.C.

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. Fill out each complaint separately. For instance, if you have neck and low back pain, identify which is your chief complaint, then list the other area as an additional complaint. Please completely fill out the forms before signing your name. You will then click SEND located at the bottom of this form. We look forward to seeing you.

Who are you?

Let's get started. Fill out the fields below to speed up your office visit.